Acute severe per vaginam bleeding with hemodynamic instability, hemoglobin drop from 71g/L to 37g/L. Recently underwent ureteric stenting to treat radiation related ureteric strictures.
Loading Stack -
0 images remaining
CT images displaying a subtle contrast blush alongside the right ureteric stent distal to crossing the of the external iliac artery and proximal ureter, evocative of acute hemorrhage. secondary to arterioureteric fistula. Left renal collecting system is obstructed and has retained contrast from prior examination.
Loading Stack -
0 images remaining
Digital subtraction iliac angiography displaying a short outpouch of contrast from the medial aspect of the proximal portion of the right external iliac artery. The close relationship to the ureter is displayed by the masked image of the stent. Then shown is selective engagement of the fistula orifice at the external iliac artery with ready passage of contrast across a short, irregular fistula to an otherwise normal appearing distal third of right ureter. Arterial stenting demonstrated in final image.
Arterioureteric fistula is a rare condition1-4. The most recent systematic review from 2009 identified 139 cases in the English language literature since 18991. It noted also that reported incidence appears to be increasing in frequency in recent years. With 93% of reports in the years 1970-2009. This increase in incidence would appear to be related to increasing prevalence of the risk factors among a select population as described below.
Authors have previously categorized AUF as being primary, secondary (Iatrogenic) and pregnancy related, with secondary being by far the most common. Pregnancy related fistulas have not been reported since the 1930s, likely due to changes in management of hydronephrosis2.
Risk factors for developing AUFs have been identified in all of the reviews to date and the commonest factor is ureteric stenting. Other factors in order of frequency in the 2009 review are oncologic radiotherapy (our patient had undergone the same for cervical cancer 30 years previously) or surgery to the pelvis, aneurysm or psuedoaneurysm of the iliac artery, urinary diversion and vascular surgery.
Almost all cases will present with gross or massive hematuria with only 17% identified as having lateralizing pain1.
Diagnosis requires a high index of suspicion. In our case at the time of deterioration a decision needed to be made between arterial imaging and cystoscopic evaluation of the hematuria. A group from the Mayo clinic suggested a diagnostic algorithm based on their series of 7 patients over 30 years. They advocate a similar approach with angiogram and provocative angiography preferred to cystoscopic management in the first instance for life- threatening hematuria in patients with risk factors for AUF4.
- 1. van den Bergh RC, Moll FL, de Vries JP, Lock TM. Arterioureteral fistulas: unusual suspects-systematic review of 139 cases. (2009) Urology. 74 (2): 251-5. doi:10.1016/j.urology.2008.12.011 - Pubmed
- 2. Bergqvist D, Pärsson H, Sherif A. Arterio-ureteral fistula--a systematic review. (2001) European journal of vascular and endovascular surgery : the official journal of the European Society for Vascular Surgery. 22 (3): 191-6. doi:10.1053/ejvs.2001.1432 - Pubmed
- 3. Bietz G, House A, Erickson D, Endean ED. Diagnosis and treatment of arterial-ureteric fistula. (2014) Journal of vascular surgery. 59 (6): 1701-4. doi:10.1016/j.jvs.2013.06.015 - Pubmed
- 4. Krambeck AE, DiMarco DS, Gettman MT, Segura JW. Ureteroiliac artery fistula: diagnosis and treatment algorithm. (2005) Urology. 66 (5): 990-4. doi:10.1016/j.urology.2005.05.036 - Pubmed